Essential Grafting in the Traumatized Nose

Essential Grafting in the Traumatized NoseFred G. Fedok, MD, FACS1,2 Jordan Rihani, MD1

1Department of Surgery, The McCollough Plastic Surgery Clinic, GulfShores, Alabama

2Department of Surgery, The University of South Alabama,Mobile, Alabama

Facial Plast Surg 2015;31:238–251.

Address for correspondence Fred G. Fedok, MD, FACS, TheMcCollough Plastic Surgery Clinic, 350 Cypress Bend Drive, GulfShores, AL 36542 (e-mail: [email protected]).

Nasal fractures are themost commonly encountered fracturesof the human skeleton and account for more than 50% of facialfractures in the United States,1with an estimate of more than50,000 nasal fractures occurring every year.1,2 These aremostcommonly due to motor vehicle accidents, interpersonalaltercations, and falls.1,3,4 Men are up to three times morelikely thanwomen to sustain a nasal fracture.3,5 An additionalconsideration is that what may be perceived as a minortrauma may have quite a large impact for the patient dueto the cosmetic and functional changes.6,7

Problematic sequelae of trauma may include simple lacer-ations, obvious nasal bone/cartilage deviation, nasal obstruc-tion, or septal destruction with subsequent saddle-nosedeformity. Scarring of the external nasal skin can lead tovisible deformities, whereas internal nasal scarring can leadto internal nasal valve obstruction. From a functional stand-point, compromise may occur as a result of nasal bonecollapse, septal deviation, or disarticulation of cartilaginousattachments.

From a clinical standpoint, nasal fracture repair is fraughtwith many considerations. There is debate regarding optimaltiming, surgical approach, and extent of repair. Fractures arequite variable in presentation given the diversity of etiology,amount of force applied, and direction of impact.8 Oneadditional unknown is how the healing process will affectfuture nasal appearance and cosmetic appearance. Seemingly

small insults may, over time, lead to further complications inboth the appearance of the nose and nasal patency. Giventhese uncertainties, patients are counseled on the possibilityof multiple surgical interventions prior to undergoing thefirst procedure.

This article explores some of the basic anatomy, currentunderstanding of nasal trauma biomechanics, current con-troversies in nasal fracture management, and techniques fornasal fracture reduction. By exploring the topic, the hope is toavoid common pitfalls and oversights when dealing with thetraumatized nose and to compile current understanding ofthe topic.

Pertinent Anatomy

Blood SupplyThe blood supply of the nose is a rich series of anastomosesbetween the external and internal carotid arteries.9 Theexternal nose is mainly supplied by the angular artery andsuperior labial arteries (external carotid artery) with contri-butions from the dorsal nasal and external branch of theanterior ethmoidal arteries (internal carotid artery). Theinternal lining of the nose is supplied by a combination ofthe sphenopalatine and greater palatine arteries (externalcarotid artery) and the anterior and posterior ethmoidalarteries (internal carotid artery).

Keywords

► rhinoplasty► cartilage grafting► corrective rhinoplasty► spreader grafts► batten grafts► caudal extension

grafts

Abstract Corrective rhinoplasty after significant nasal trauma is a much different entity thanelective rhinoplasty or rhinoplasty after minor trauma. The more significant the degreeof trauma the patient is subjected to, the greater the deleterious effects will be on thesoft tissue and skeletal elements of the patient’s nose. With this disruption of theanatomic integrity and dynamics of the nose, the patient experiences deformity anddysfunction of the nose. This may be minor and transient or may be lifelong anddisabling. In this article, the authors review some of the more long-term aspects of nasaltrauma and provide the reader with insights to the use of cartilage grafting techniquesthat are useful in the management of posttraumatic nasal deformity and airwayobstruction.

Issue Theme Nasal Trauma; Guest Editor,John L. Frodel, Jr., MD

Copyright © 2015 by Thieme MedicalPublishers, Inc., 333 Seventh Avenue,New York, NY 10001, USA.Tel: +1(212) 584-4662.

DOI http://dx.doi.org/10.1055/s-0035-1555621.ISSN 0736-6825.

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mailto:[email protected]

http://dx.doi.org/10.1055/s-0035-1555621

http://dx.doi.org/10.1055/s-0035-1555621

Notable external landmarks for nasal blood supply are thecolumella which possesses the columellar artery (branch ofsuperior labial artery), nasal ala which is traversed by thelateral nasal artery (branch of the facial artery), lateral nasalsidewall along which runs the angular artery (terminalbranch of the facial artery), medial palpebral ligament abovewhich emerges the dorsal nasal artery (terminal branch of theophthalmic artery), and keystone area where the externalnasal branch of the anterior ethmoidal artery (branch of theinternal carotid artery) emerges from between the nasalbones and upper lateral cartilages.9

Notable internal landmarks for nasal blood supply includethe posterior edge of the middle turbinate where the sphe-nopalatine artery emerges from the sphenopalatine foramen(branch of external carotid artery), the openings of theincisive canal in the anterior nasal floor (branch of externalcarotid artery), anterior and posterior ethmoidal arteries inthe superior nasal cavity (branches of internal carotid artery),and Kiesselbach’s plexus in the anteroinferior portion of theseptum, where many of these vessels converge.

InnervationBranches of the trigeminal nerve are mainly responsible forsensation of the nose. The external nose is mainly supplied bybranches of the infraorbital nerve to the lateral nasal walls,columella, and vestibule. The nasal tip and dorsum receivecontributions from the supratrochlear and anterior ethmoi-dal nerve (from the nasociliary nerve branch of the ophthal-mic nerve). Internally, the lateral walls and septum aresupplied by the sphenopalatine ganglion and branches ofthe anterior ethmoidal nerve. A branch of the sphenopalatineganglion is the nasopalatine nerve, which descends down theseptum to travel under the periosteum along the floor of thenose to enter the incisive foramen. Disruptions can lead toparesthesias or numbness of the central maxillary incisorsfollowing nasal surgery.

Skin and Soft Tissue EnvelopeThe nasal skin and soft tissue envelope varies in thickness andcomposition in different regions of the nose. The upper andlower thirds of the nose possess a thicker skin envelope, withthe thinnest skin located in the middle third at the rhinion.Beneath the skin is the fibromuscular layer of the nose (alsoknown as the nasal SMAS) which allows movement for facialexpressions and nostril flaring.10 The underlying support ofthe nose is a combination of bone and cartilage that helpsupport the skin and provide a rigid framework to preventcollapse of the nasal passages during inspiration. The foun-dation of the nose is built upon a bony platform that allowsthe nose to structurally span the pyriform aperture. Thepyriform aperture is a heart-shaped opening composed ofthe nasal bones superiorly and the sharp edges of the nasalsurfaces of the maxilla, both laterally and inferiorly, as theycurve around to join the anterior nasal spine.

Osseous Framework of the NoseThe nasal bones comprise the bony vault and are pairedpyramid-shaped bones that abut the nasal process of the

frontal bone superiorly and the frontal process of the maxil-lary bone laterally. They are joined in the midline and areconnected by fibrous attachments to the upper lateral carti-lages inferiorly. Measurements of average nasal bone lengthare around 24 mm11,12 but vary in patients based on age andrace. The thickness of the nasal bones is thickest superiorly,thinning inferiorly. The bones tend to be hourglass-shapedwith the widest points superior and inferior and a narrowingof the nasal vault near themedial canthus. The junction of thenasal process of the frontal bones and paired nasal bonescomprises the nasal root and corresponds with the radix. Theposition of the radix should be located at the upper eyelidcrease, but may be lower in some ethnicities.13,14 Posterior tothe superior nasal bones, as part of the medial orbit, lies thelacrimal bone, which the surgeon should be aware of whenperforming osteotomies.

Inferior to the nasal bones are connections to the bonyseptum, which are composed of the perpendicular plate ofthe ethmoid bone, superiorly, and the vomer, inferiorly. Thesetwo bones allow formation of a buttress to connect thecribriform plate of the ethmoid bone to the nasal floor.Beneath the vomer lies the nasal crest of the maxilla, anteri-orly, and the nasal crest of the palatine bone, posteriorly.Underneath these crests is the support of the anterior nasalspine and palatine process of themaxillary bone. The anteriornasal spine is the attachment of the caudal septum and formsthe posterior septal angle (►Figs. 1 and 2).

Cartilaginous Framework of the NoseThe most important structural cartilage of the nose is thenasal septum, which composes the lower third of the nose.Described as quadrilateral in shape, the average size of septalcartilage is around 33 mm in height and 37 mm inwidth, andvaries with gender and ethnicity.15 The septum is connectedposteriorly to the perpendicular plate of the ethmoid andvomer bones. Along the dorsal surface, the septum is attachedon either side to the upper lateral cartilages. The caudal end ofthe dorsal septum begins a triangulated turn to the anteriornasal spine. These angles are known as the anterior, interme-diate, and posterior septal angles. The width of the septalcartilage is variable, with thinner areas near the caudal edgeand central portions and thicker cartilage near bony articu-lations.8 Recent evidence suggests that the collagen andglycosaminoglycan composition varies when comparing thedorsal septum to the caudal septum.16

The lower two-thirds of the nose, or cartilaginous nasalvault, is built on the support of the nasal septum andcomposed of the paired upper lateral cartilages, pairedalar cartilages, and minor contributions from the sesamoidcartilages. The upper lateral cartilages form themiddle vault,are described as trapezoidal in shape, and originate beneaththe nasal bones. Medial connections between the septumand upper lateral cartilages form part of the internal nasalvalve with an ideal angle of 10 to 15 degrees.17 The alar, orlower lateral, cartilages are C-shaped cartilages that curvefrom the pyriform aperture, traveling medially to form thenasal tip, then inferiorly to rest near the anterior nasal spine.The alar cartilages are thus divided into three segments:

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Essential Grafting in the Traumatized Nose Fedok, Rihani 239

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lateral crus, intermediate crus, andmedial crus. The junctionof the intermediate and lateral crura is the most projectingpoint of the nasal tip and is known as the tip-defining point.Support of the lower lateral cartilages derives from attach-ments to the pyriform aperture, which contain the sesamoidcartilages, superior attachments to the upper lateral carti-lages at the scroll area, attachments to the nasal septummedially, and attachments to the contralateral alar carti-

lages. These cartilages allow support of the external nasalvalve and are the defining external feature of the lower thirdof the nose.

Biomechanics of Nasal Trauma

Nasal injury secondary to the application of superphysiologicforces to the nosemanifests in several traumatic patterns. The

Fig. 2 Drawing depicting skeletonized nasal anatomy revealing relationship of quadrangular cartilage of the septumwith the bony portions of theseptum, nasal bones, and the anterior nasal spine. (Reprinted from Becker DG, Park SS. Revision Rhinoplasty. New York: Thieme MedicalPublishers; 2007:98, Fig. 9–4.)

Fig. 1 Drawing depicting skeletonized nasal anatomy revealing relationship of the nasal bones, the upper lateral cartilages, and the lower lateralcartilages. (Reprinted from Becker DG, Park SS. Revision Rhinoplasty. New York: Thieme Medical Publishers; 2007:97, Fig. 9–3.)


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amount of energy, the duration, and how force is distributedto the tissues are important factors in determining theresultant injury pattern. A blunt injury from a fall creates amuch different outcome than a laceration from a knife or ablast from a bullet injury. The different combinations ofvector and force result in a varying constellation of fracturesof bones and cartilage, as well as soft tissue injuries.

The nasal bones require the least amount of force tofracture compared with the other bones of the face.18 Al-though not proven, this presumptive shock absorber functionis beneficial when considering the adjacent vital structures,including the orbits, ethmoid sinuses, and cribriform plate. Aslittle as 16 to 66 kPa can induce a lateral displacement of nasalbones, as demonstrated in cadaveric studies. A variation ofdirection will determine the amount of force required tocause a fracture, with frontal impacts generally requiringmore force to cause a nasal fracture than impacts from theside.18 For frontal types of axial injuries, the nasal septum,and cartilages bear the brunt of force. Multiple investigatorshave described fracture patterns through cadaveric studies,showing many fractures originate behind the anterior nasalspine and traveling superiorly toward the regions of theperpendicular plate of the ethmoid bone.18–20 High-energyinjuries, as seen in motor vehicle accidents, can generateextremely large amounts of force and, when applied in anaxial pattern, can result in telescoping injuries or saddledeformities that may be present in conjunction with otherfacial fractures including naso-orbito-ethmoidal (NOE), orbit-al, or frontobasilar fractures.18,21–23

Shearing forces come into play in pediatric nasal trauma,where the more flexible cartilages and bone are less suscep-tible to fracture. As a result, small feeding vessels to thecartilage may rupture and cause hematomas under themucoperichondrial flaps. Given the avascular nature of carti-lage and its dependence on surrounding mucosa, cartilagenecrosis may occur as soon as 24 hours after injury andprogress to abscess formation.24 Even without an obviousoutward appearance of a nasal fracture in children, suspicionof septal hematoma should remain high in the presence ofnasal trauma25 (►Fig. 3).

Fractures, displacement, and avulsions of cartilaginousstructures are less apparent as these injuries are rarely visibleon computed tomography (CT) or X-ray. The resultant nega-tive impact on the anatomy, however, contributes to defor-mity and airway obstruction. Avulsions of the upper lateralcartilages are also frequently initially masked by swelling andhemorrhage (►Fig. 4).

Clinical Presentation and Diagnosis

Patients with a history of nasal trauma may present withisolated nasal fractures or fractures in combination withother facial injuries. A thorough history including prior nasaltrauma, surgery, and preexisting deviations should be docu-mented. Typical histories may include epistaxis, nasal pain,nasal deformity, edema, bruising, and nasal obstruction. Ahistory of epistaxis indicates damage to the mucosal liningand should raise suspicion for cartilage injury. The mecha-

nism of injury, including force and direction, should beelicited. High-velocity and high-energy injuries may be com-pounded by tissue loss, additional facial fractures, or criticalinjuries. For example, a group of patients with a documentedorbital or nasal fracture were shown in one study to have a4.5% risk of having an associated cervical spine injury.26

Examination should be performed as promptly as possiblein the case of recent trauma. It is helpful to make a note ofpretraumatic appearance with the assistance of a driver’slicense or photograph. A nasal examination begins with anexternal observation of edema or ecchymosis. Lacerations ofthe skin, soft tissue, or cartilage should be noted. Obviousdeviation of the nose and septum should be documented.Obvious deviations may be noticeable immediately, but sub-tle injuries may be masked by edema and become moreevident as swelling subsides and fibrosis occurs. Specificdeformities of the nose and nasal dorsum may include aforeshortened nose, saddle nose, alar retraction, crookednose, septal deviation, middle vault collapse, and cicatrix ofthe external skin envelope or nasal lining (►Fig. 5). In anacute injury, edema will frequently mask deformities andwarrant reevaluation in 5 to 8 days.

The evaluation of the soft tissue is important to aid in thediagnosis of the potential injuries in the underlying skeletalfeatures. The condition of the soft tissues will also influencethe potential timing of any repair efforts. For instance, alaceration of the skin may overlie a disruption of the lateralcrura. An avulsion of skin may be indicative of an avulsion ofcartilage or bone. Massive swelling in the soft tissue envelopemay delay surgical correction of the delicate underlyingcartilaginous framework until the swelling subsides. Finally,skin with vascular compromise secondary to stellate lacer-ations may be put at further risk with early attempts atsurgical correction of the nasal skeleton.

Examination of the nasal passages should be performedwith anterior rhinoscopy. Nasal patency can be evaluated byexamining the nose for internal and external valve collapseand the response to a modified Cottle maneuver. Palpation of

Fig. 3 Axial computed tomography (CT) showing septal hematomathat has progressed to abscess formation.



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the nose should note any step-off deformities, crepitus, andswelling or stiffness. Support of the dorsum and nasal tipshould be assessed as an indicator of septal integrity.22 Ifthere is a question of a septal hematoma, a cotton tipapplicator can be used to palpate the area of concern. Nasalendoscopy may be necessary to assess for posterior septalfractures. Septal injuries are relatively common. Recent stud-ies confirm a high frequency of corresponding cartilaginousfractures with nasal bone fractures.7,19 Mucosal lacerationsand epistaxis are also predictive indicators of septal trauma.19

Complications of septal fracturemay include septal deviation,loss of support, nasal obstruction, septal hematoma, septalcartilage necrosis, septal abscess, and saddling. As mentionedpreviously, suspicion for septal hematoma should remainhigh in the pediatric population despite an absence of exter-nal findings. Any finding of a hematoma warrants decom-pression and stabilization.

With the increasing availability of CT scanning, manypatients receive a maxillofacial CT to assess for nasal andother facial fractures on arrival to an emergency facility. The

Fig. 4 (A) Preoperative photograph of the patient with traumatic avulsion of left upper lateral cartilage and septal deviation. (B) Postoperativephotograph of the patient after surgical correction via an open approach, medial osteotomies, the placement of bilateral extended spreadergrafts, the placement of a columellar strut, intra- and interdomal sutures, and a soft cap graft.

Fig. 5 (A–C) Preoperative photos of the patient with history of severe nasal trauma. (D–F) Postoperative photographs of the patient afterreconstructive septorhinoplasty via open approach and multiple cartilage grafting techniques as featured in this manuscript.



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value of CT scanning in the evaluation of isolated nasalfractures, however, is still a matter of debate.19,27

Classification of InjuriesA thorough discussion of nasal fracture classification isoutside of the scope of this manuscript. The reader is referredto the discussions of this topic by Murray et al and Ondiket al.18,28

Timing of Repair

There is limited consensus on the optimal timing of repair ofposttraumatic nasal deformities and functional issues, be-cause nasal injuries can be quite varied and present different-ly depending on the clinical setting. Situations that should beaddressed promptly include lacerations and other soft tissueinjuries, acute soft tissue loss, and acute severe saddling.Moreminor disruptions can frequently be left to allow swelling tosubside for several weeks. At a timeframe of 6 weeks or later,nasal surgery of a more refined nature can be performed toachieve optimal aesthetics. When there is an acute deviationwith nasal fracture, acute osteotomies may be performed asrecommended by Ondik et al.28

In general, the authors address soft tissues injures, avul-sions, and exposed cartilage very early in the clinical course.The repair of major saddling or significant deviations isaddressed in a subacute timeframe, and osteotomies andlimited septoplasty may be performed. More minor correc-tions that require more of a rhinoplasty grade result areperformed in a delayed timeframe to allow swelling to becompletely resolved.

Commonly Used Grafting Techniques

Whether or not the surgeon uses an open or closed approachin the repair of the traumatic nose is a matter of personalexperience and preference. Given the uncertainty of thepatient’s posttraumatic anatomy, in many situations, therewill be an advantage to performing these maneuvers via anopen approach.

A review of commonly used grafting techniques inrhinoplasty after trauma follows. Clinical presentationsthat can be addressed with the techniques reviewed in-clude foreshortening of the nose, saddling of the dorsum,columellar retraction, alar retraction, the crooked nose,septal deviation, middle vault collapse, cicatrix, and others.Although this article is focused on the posttraumatic situa-tion, the techniques are also valuable in primary andrevision rhinoplasty.

Sources of Grafting MaterialsThe authors routinely use cartilage to replace, buttress, andaugment the skeletal structures of the nose. Grafting withbone is uncommon and is usually restricted to the use ofcantilevered split calvarial bone grafts for the restoration ofcentral nasal support in cases of complete saddle nosedeformity as seen with nasoethmoid fracture. Thin piecesof ethmoid bone are also occasionally used in septal cartilage

repair. In many instances, septal cartilage is the preferredcartilage to be used in rhinoplasty. In the situation of theposttraumatic nose, the nasal septal cartilage may be com-promised, excessively crooked, or deficient. At this point intime, many surgeons consider the rib to be the next preferreddonor site. The advantage of a rib donor site is the abundanceof cartilage that can be carved into a varietyof useful shapes tobe used for grafting.

Fig. 6 Harvest of auricular cartilage via a posterior approach. (A)Intraoperative photograph showing placement of incision lateral to thepostauricular sulcus. This positions the wound over the areas ofcartilage to be harvested and facilitates closure. (B) Exposure ofunderlying postauricular musculature and perichondrium that will bedivided and retracted. (C) Isolation dissection of cartilage of cymbaconcha.



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Auricular cartilage is still used and is frequently chosen fora variety of factors, one of which may be the patient’s wish toavoid the harvesting of rib cartilage. Like the septal cartilagedonor source, however, even auricular sources can be limitedin the provision of adequate donor material.

Other tissues that have utility in reconstructive andcorrective rhinoplasty are perichondrium from costal andauricular sources and fascia from the temporalis muscle.Many surgeons routinely use homologous grafting materi-als; the authors of this manuscript prefer autogenousmaterials. Given the multiple donor sources availablefrom a particular patient, there is usually sufficient carti-lage at hand without creating excessive donor sitemorbidity.

Septal cartilage is harvested at the time of septoplasty. Theauthors routinely elevate bilateral septal mucoperichondrialflaps to aid in cartilage harvesting. Sufficient dorsal andcaudal support of the septumhas to be preserved. It is optimalto leave approximately 1.5-cm-wide residual struts. However,in some circumstances, as little as 1 cm may be adequate.Acceptable harvested cartilage must have sufficient dimen-sions to carry out the necessarygrafting tasks to be useful. Theadvantage of using septal cartilage is that it is readily availableduring nasal surgery. Disadvantages and risks are the fre-quent lack of sufficient cartilage and that harvestingmay leadto septal perforation and diminishing support of the nasaldorsum.

Auricular cartilage can be harvested via either anterior orposterior incisions (►Fig. 6). The amount of cartilage that canbe used will be relatively limited if one is to avoid creating adeformity. In essence, both the cymba concha and the conchacavum can be harvested. Leaving the intervening strut ofcartilage will preserve the support of the ear and lessendeformity. An advantage of the auricular cartilage donorsite is that the ears are close to the field during rhinoplasty.Disadvantages and risks include the relative limited amountof cartilage that can be harvested and also the unforgivingnature of auricular cartilage when placed along the dorsum.Unless precisely contoured, the grafts frequently reveal theiredges and ridges through the overlying nasal skin envelopeover time.

A major advantage of the use of costal cartilage in correc-tive and revision rhinoplasty is the availability of sufficientcartilage for most contingencies. In the younger patient, thecartilage is relatively soft and easily modifiable. The costalarea is also an excellent source of a hearty perichondrium thatcan be used to help thicken the nasal soft tissue skin envelope,thus providing good cover over cartilage grafts. Disadvan-tages of the use of the chest wall for cartilage harvest arenumerous and include the risk of significant pain, as well asthe small but very real risk of pneumothorax. In the olderpatient, the cartilage may be calcified and unusable forcarving into adequate graft sizes. Finally, there is a risk ofgraft warping, which can occur in spite of recommendationsabout balance carving and other modifications. Nevertheless,in the patient who needs a large amount of cartilage to use forgrafting, the chest wall offers a reasonable alternative(►Fig. 7).

Spreader Grafts, Extended Spreader Grafts, andArticulated Spreader GraftsSpreader and extended spreader grafts are used in a variety ofways to address traumatic anatomic nasal derangements.Spreader grafts can be used to correct deficiencies in themiddle vault of the nose including collapse and avulsion ofthe upper lateral cartilages, to “brace” a fractured septum to acorrected midline position, and to serve to cosmeticallyrestore the contour of the nasal sidewall. Spreader graftsare used in the correction of dorsal saddling, functionalcollapse of the nasal sidewall, internal nasal valve collapse,and the crooked nose. The role of spreader grafts in thecorrection of the severely deviated septum and the crookednose is fundamental to reestablishing a straight midline. Theyare used in isolation and also in conjunctionwith other grafts,including caudal extension grafts, columellar strut grafts, and

Fig. 7 Intraoperative photograph of harvest of costal cartilage andperichondrium from right chest: (A) perichondrium removed fromintact rim, (B) rib cartilage removed and access incision, (C) demon-stration of cartilage being carved into usable grafts.



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nasal sidewall grafts. These grafts can vary in width, thick-ness, and length, depending on donor site considerations andthe purpose in using the grafts. Variations of the designs of

spreader grafts include extended spreader grafts29,30 andpistol grafts.30 Finally, an articulated spreader graft may beconstructed by suturing the spreader grafts to a caudal

Fig. 9 Intraoperative photographs of patient undergoing the construction of an articulated spreader graft: (A) The septum is isolated by performingseptoplasty, elevation of bilateral mucoperichondrial flaps, and division of upper lateral cartilages from the septum, Note septum is foreshortened, (B) Theseptum is projected and lengthened by the placement of a caudal extension graft. (C, D) Articulated spreader graft complex is constructed by the suture ofbilateral spreader grafts to the caudal extension graft to adjust overall height and length of a new anterior superior septal angle.

Fig. 8 Drawings depicting the dynamics and structure of “articulated” spreader grafts. (A) Reference positioning of bilateral extended spreader graftssutured to residual septum and septal caudal extension graft. The upper lateral cartilages are divided away from the septum. The lower lateral cartilages arenot depicted. (B) By articulating the attachments between the spreader grafts and the septal caudal extension graft, the position and shape of the “new”septal caudal margin can be changed. After the desired positioning is obtained, the grafts undergo final suture fixation. This articulated spreader graftcomplex, in turn, will be a key factor in the final shape and height of the nasal dorsum and nasal tip positions.



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extension graft or vertical “strut,” thus creating a new “L-strut” for the nose (►Figs. 8 and 9).

By adjusting the position of the extended spreader graftsalong the strut or caudal extension graft, the articulatedspreader graft complex can be used to lengthen the noseand to change tip rotation and projection of the dorsum andtip. Spreader grafts can be created using auricular, septal, orrib cartilage. The need to construct the spreader grafts with asizeable straight piece of cartilage will frequently influencethe donor site selection. The use of septal cartilage and ribcartilage is preferred many instances.

Dorsal Augmentation and Nasal Sidewall GraftsGraft selection for the augmentation of the nasal dorsum isdependent on the degree of saddling of the nose, the antici-pated volume and dimension of the desirable correction, andthe remaining skeletal support of the nasal dorsum. Graftsmaybe created to restore the entire dorsum or may be limited toonly restoring selected portions of the nasal dorsum andsidewalls.31 Restoration of support is necessary when therehas been disruption of central nasal support along themidlineaxis caused by a significant loss of septal integrity, as seenwithcomminuted fractures, cartilage loss, and perforation. In thesesituations, the augmentation will have to be constructed toprovide support by being cantilevered or be supported byother structural mechanisms, that is, spreader grafts. A new L-strut may be created to bridge a deficient support mechanismbetween the frontal or nasal bones and the maxilla. This can

usually be done with cartilage grafts. In extreme situations,such as the complete loss of central nasal support, splitcalvarial bone may be used in a cantilevered fashion.32

Graft materials include septal cartilage, rib cartilage, andlayered auricular cartilage. It is sometimes helpful to use com-posite grafting with fascia and diced cartilage.33 Recently, therehavebeen several reports about dorsal augmentation performedwith diced cartilage held together with biological adhesives.34 Inthe case of the posttraumatic nose, septal cartilage is frequentlydeficient. Rib cartilageprovides adequatevolumeanddimensionto restore large amounts of volume and also has the structuralstrength to restore a new L-strut with connection with a caudalextension graft or columellar strut. If only volume is necessary,layered auricular cartilage may be used. The placement oftemporalis fascia or rib perichondrium over the reconstructeddorsum is helpful to thicken the overlying thin skin and mini-mized the risk of the visibility of postoperative dorsal irregulari-ties (►Figs. 10 and 11).

Septal Replacement and Caudal Extension GraftsCaudal extension grafts have been described by severalauthors as a method to correct the foreshortened nose anddeficiencies of the septum that are either the result offractures or loss of cartilage. If the cartilage graft is used toreplace a portion of the caudal septum that ismissing becauseof previous surgery or trauma, it is sometimes referred to as aseptal replacement graft. The caudal extension grafts can beusedwhen there is sufficient integrity of the terminal portion

Fig. 10 (A–C) Preoperative photographs of the patient with history of severe nasal trauma with resultant saddling of the nasal dorsum, foreshortening ofthe nose, and septal perforation. (D–F) Postoperative photographs of the patient after reconstructive septorhinoplasty performed via an open approach.Corrections included the repair of the septal perforation with temporalis fascia, dorsal augmentation with a two-layer auricular cartilage graft andlengthening the nose, and derotating and projecting the tip with extended spreader grafts articulated with a columellar strut.



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of the septum to allow the securing of the graft to the remnantof the septum. It can also be used in a modified form andincorporated into an articulated spreader graft. These graftsare typically used in underprojected and foreshortened nosesto increase dorsal height, tip projection, and to lengthen thenose. Septal, auricular, or rib cartilage is used to create thegrafts (►Figs. 12 and 13).

Columellar Strut GraftsStrut grafts have been described in a variety of ways. Forthis discussion, the strut grafts described are those that aresutured between the medial and intermediate crura. Strutgrafts can be used to reestablish tip projection, to straight-en deformed medial crus, replace cartilages that have beendestroyed by trauma, widen the columella, and to providefurther caudal projection of the columella. Typically, septalor rib cartilage is the preferred grafting material for thecolumellar strut. Auricular cartilage can be used, but caremust be taken to find an optimally straight piece or lami-nate two opposing pieces together. This elongated rectan-gle-shaped cartilage graft is placed between the medialcrus so that it spans from the anterior nasal spine towardthe intermediate crura. It is a frequently used and powerfulgraft for increasing or preserving nasal tip support andprojection. Some surgeons place columellar struts prophy-lactically to resist contractile forces that occur following

Fig. 11 (A–C) Preoperative photographs of the patient who presented 10 years after a severe playground accident. Examination revealedsaddling of the bony and cartilaginous dorsum with a foreshortened nose, contraction of the soft tissue envelope, severe septal deviation, and leftmiddle vault collapse. (D–F) Postoperative photographs of the patient after repair was performed via an open approach, with septoplasty,application of bilateral extended spreader grafts articulated with a caudal extension graft creating a new L-strut constructed from a costalcartilage donor site. She also underwent medial and lateral osteotomies. After the initial reconstructive procedure, she underwent a secondaryprocedure to take down a small dorsal convexity and further augment the columella.

Fig. 12 Intraoperative photographs depicting two surgical steps inthe use of a caudal extension graft. (A) the graft has been placed at thecaudal end of septum and is positioned to control projection andlength with the aid of two 25-gauge needles. (B) The graft has beensutured to the caudal end of the septum and is now being furthersecured by suturing two spreader grafts to it in the manner ofarticulated spreader grafts.



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septorhinoplasty, as well as resisting the ptosis of the nasaltip acquired with aging and lack of support from theseptum. One drawback of placing a columellar strut canbe avoided by leaving a cushion of soft tissue above thenasal spine, which helps prevent the “clicking” of the strutthat some patients experience35 (►Fig. 14).

Tip GraftsThere have been a variety of tip grafts described that havevarious functions, including those designed to lengthen thenose, improve the shape of the tip, influence tip rotation,increase projection, and to soften irregularities at the level to

tip. Cap grafts36 placed on the nasal tip or supratip lobule canbe fashioned from conchal, septal, or cephalic trim cartilage,and are used to increase tip projection or for definition of thesupratip break. Shield-like grafts37 are used in the nasal tipand extend to the infratip lobule. Caution should be taken forall tip grafts used in thin skin patients where additionalcoverage with fascia, morselized cartilage, or crushed carti-lage should be considered (►Fig. 15).

The Lateral Crural Strut GraftThe lateral crural strut graft is used by the senior authorprimarily to change the axis of the lateral crus of the lower

Fig. 13 (A) Pre- and (B) postoperative photographs of the patient who underwent revision septorhinoplasty after trauma and previouslysurgeries. He patient presented with nasal obstruction. Examination revealed a lack of support of the distal two-thirds of the nose and a positivemodified Cottle maneuver. (C) Intraoperatively the patient was found to have an absence of his caudal septum. (D) Repair involved the use ofbilateral lateral crural strut grafts, a left spreader graft, and a caudal extension graft. The photograph shows the caudal extension graft in place.The cartilage was obtained from a rib donor site.

Fig. 14 Intraoperative photograph depicting the suturing of a colu-mellar strut between the medial crura. Note that the strut is suturedmore posterior to allow the most caudal aspect of the medial crural toimpart the contour of the columella.

Fig. 15 Intraoperative photograph depicting the suturing of a shield-like tip graft to the intermediate crural of this traumatized nose. In thisposition the graft will serve to increase tip projection and nasal length.



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lateral cartilage, to support the ala, improve the airway, and toimprove the lobule-alar contour. These grafts are placedbetween the vestibular lining and the lateral crus(►Fig. 16). The lining can be undermined from the postero-lateral two-thirds of the lateral crus to a point approachingthe dome. The lateral undermining may extend over thepyriform aperture to allow for further support of the lowerlateral cartilages.38 The grafts have considerable utility in thecorrection of external nasal valve and intervalve collapse.Inspection of the support of the ala during inspiration and theuse of a modified Cottle maneuver will help the surgeonassess alar support and the need for the use of this graftingtechnique.

Alar Batten GraftThe alar batten graft is used in similar circumstances to thosein which the lateral crural strut graft is used. The seniorauthor, however, uses this grafting technique preferentially tothe lateral crural strut graft technique when there is asignificant need to change the actual shape and contour ofthe lateral crus itself. This may be encountered after trauma,after previous rhinoplasty, or with developmental deformity.The alar batten graft is different from the lateral strut graft inthat it is sutured on the anterior surface of the lateral crus ofthe lower lateral cartilage. In this position, the graft providesimproved integrity, support, and shape to the lateral crus,which is imparted to the ala. The sculpting and placement of

the graft determines thefinal resultant shape. These grafts areplaced either endonasally through an intercartilaginous inci-sion into a pocket overlying the lateral crus or via an openrhinoplasty approach and sutured in place. They may vary inlength and dimension andmayextend along the entire lateralcrus39 (►Fig. 17).

Contour Grafts and Composite GraftsContour grafts and composite grafts are used to providesupport, change the shape of the alar margin, and to changethe alar-columellar relationship. Alar composite grafts andcontour grafts are indicated for the treatment of alar notchingor asymmetric rim height that may occur as a result ofscarring. They will aid in the correction of alar retractionand the hanging columella. Whether or not a contour graft orcomposite graft is used depends on the clinical situation.Factors to be considered are the stiffness of the alar marginand other soft tissue factors. If it appears that there is anactual vertical deficiency of lining along the alar margin, thesenior author will commonly use a composite graft. For alardefects greater than 3mm, alar composite grafting is typicallyrecommended. Cymba concha cartilage with overlying skin istaken from the lateral surface of the ear and inserted in thevestibular incision. Typically, grafts are less than 1 cm in sizeto optimize graft survival. These techniques may be accom-plished by either an open or closed technique.

Other Grafts and Other ConsiderationsPosttraumatic rhinoplasty presents as a surgical challenge.The magnitude of this challenge correlates directly with theextent of the original trauma. When there has been a signifi-cant disruption of the normal nasal anatomy and contour, thesurgical challenge increases. Even after early adequate repairof cartilaginous and boney deformities, the patient’s nosecontinues to change over time as the destructive result of theenergy dissipated through the nasal tissues. Deformity anddysfunction manifest with the resolution of swelling andevolving scar contraction. The patient may therefore presentearly or late after an injury. Revision surgery is commoncompared with elective rhinoplasty (►Fig. 18).

Fig. 16 Intraoperative photograph depicting the placement of alateral crural strut graft via an endonasal approach, (A) dissection ofprecise pocket between the underside of the lateral crus and thevestibular lining, (B) placement of graft that will extend under themajority of the lateral crus to the pyriform aperture.

Fig. 17 Intraoperative photograph depicting the placement of an alarbatten graft via an external approach, the graft is sutured into positionusing absorbable sutures.



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The challenge frequently includes the need to replaceand restore the underlying nasal anatomy. A wide reper-toire of grafting techniques is important to address a widevariety of deformities. Stabilization grafts become as im-portant as the selection and sculpting of the grafts if thesurgery is to be successful. In these surgeons’ hands, thedirect suturing of grafts has been demonstrated to bedependable and reproducible. The creation of precisionpockets for the placement of grafts endonasally has equallybeen reliable. These authors have limited experience in theuse of adhesives.

In some areas of the nose that come under tension, such asthe nasal dorsum and the tip, additional care has to beexercised to prevent imperfectly contoured grafts from beingvisible over time. These authors frequently utilize methods tosoften the graft contour, such as moralization of edges or theuse of crushed cartilage. Fascia and perichondrium grafts arefrequently added to thicken the soft tissue cover over carti-lage grafts.

Finally, somementionmust bemade about themorbiditiesof these procedures. All the grafting and harvesting techni-ques presented herehavebeen performed numerous times by

Fig. 18 Series of photographs of the patient who presented after a nasal fracture (A) initial presentation, (B) the patient 3 months later afterundergoing secondary septorhinoplasty with septoplasty and osteotomies, (C) the patient 2 years after the procedure, (D–F) the patient 12 yearslater and without a history of intervening trauma presented with further crookedness to her nose, tip asymmetry, and flattening of the left ala,(G–I) secondary repair involving the use of lateral osteotomies, dorsal augmentation with auricular cartilage, a left alar batten graft, and acomplete strip on the left.



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these authors. It is felt that all of the harvesting techniqueshave acceptable morbidities to justify their use in the resto-ration of these patients’ appearances and nasal function. Itshould be remarked that these procedures do have risks thathave to be considered as these procedures are executed.Donor site complications include infection, pain, pneumotho-rax, deformity, and hematoma.

Conclusion

This manuscript has presented several grafting techniquesthat are frequently used by these authors. These techniqueshave been found to be reliable and usable in a variety ofpatients after trauma, as well as in the setting of revision andprimary rhinoplasty. This is not meant to be a comprehensiveof all available techniques, and the readers are encouraged toinvestigate other sources beyond the associated references togain an even broader appreciation of the repertoire of graft-ing techniques available.

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Documents

Essential Grafting in the Traumatized Nose